Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Acute Respiratory Infection Incidence and Outpatient Antibiotic Prescription Patterns in People With or Without Human Immunodeficiency Virus Infection: A Virtual Cohort Study

Background

Inappropriate antibiotic use in acute respiratory infections (ARIs) is a major public health concern; however, data for people with human immunodeficiency virus (PWH) are limited.

Methods

The HIV Virtual Cohort Study is a retrospective cohort of adult Department of Defense beneficiaries. Male PWH cases (n = 2413) were matched 1:2 to controls without HIV (n = 4826) by age, gender, race/ethnicity, and beneficiary status. Acute respiratory infection encounters between 2016 and 2020 and corresponding antibiotic prescriptions were characterized as always, sometimes, or never appropriate based on International Classification of Diseases, Tenth Revision coding. Incidence of ARI encounters and antibiotic appropriateness were compared between PWH and controls. Subgroup analyses were assessed by CD4 count and viral load suppression on antiretroviral therapy.

Results

Mean rates of ARI encounters were similar for PWH (1066 per 1000 person-years) and controls (1010 per 1000 person-years); however, the rate was double among PWH without viral load (VL) suppression (2018 per 1000 person-years). Antibiotics were prescribed in 26% of encounters among PWH compared to 34% for controls (P ≤ .01); antibiotic use was "never" appropriate in 38% of encounters with PWH and 36% in controls. Compared to controls, PWH received more sulfonamides (5.5% vs 2.7%; P = .001), and variation existed among HIV subgroups in the prescription of sulfonamides, fluoroquinolones, and β-lactams.

Discussion

Acute respiratory infection encounters were similar for PWH and those without HIV; however, PWH with lower CD4 counts and/or nonsuppressed VL had more frequent ARI visits. Inappropriate antibiotic use for ARIs was high in both populations, and focused interventions to improve antibiotic appropriateness for prescribers caring for PWH should be pursued.

Harm reduction must be recognised an essential public health intervention during crises

The COVID-19 had a substantial impact on the provision of harm reduction services for people who use drugs globally. These front-line public health interventions serve a population that due to stigma, discrimination and criminalisation, faces barriers to accessing health and social services and are particularly vulnerable to public health crises. Despite this, the pandemic has seen many harm reduction services close, reduce operations or have their funding reduced. Simultaneously, around the world, harm reduction services have been forced to adapt, and in doing so have demonstrated resilience, flexibility and innovation. Governments must recognise the unique abilities of harm reduction services, particularly those led by the community, and identify them as essential health services that must be protected and strengthened in times of crisis.

Decolonizing drug policy

This paper reviews evidence of how drug control has been used to uphold colonial power structures in select countries. It demonstrates the racist and xenophobic impact of drug control policy and proposes a path to move beyond oppressive systems and structures. The 'colonization of drug control' refers to the use of drug control by states in Europe and America to advance and sustain the systematic exploitation of people, land and resources and the racialized hierarchies, which were established under colonial control and continue to dominate today. Globally, Black, Brown and Indigenous peoples are disproportionately targeted for drug law enforcement and face discrimination across the criminal system. These communities face higher arrest, prosecution and incarceration rates for drug offenses than other communities, such as majority populations, despite similar rates of drug use and selling among (and between) different races. Current drug policies have contributed to an increase in drug-related deaths, overdoses and sustained transnational criminal enterprises at the expense of the lives of people who use drugs, their families and greater society. This review provides further evidence of the need to reform the current system. It outlines a three-pillared approach to rebuilding drug policy in a way that supports health, dignity and human rights, consisting of: (1) the decriminalization of drugs and their use; (2) an end to the mass incarceration of people who use drugs; (3) the redirection of funding away from ineffective and punitive drug control and toward health and social programs.

Factors associated with erectile dysfunction diagnosis in men with HIV infection: a case-control study

OBJECTIVES

HIV infection is associated with increased risk of erectile dysfunction (ED); however, factors associated with ED remain unclear. We evaluated the prevalence of ED among men living with HIV and factors associated with ED diagnosis in the US Military HIV Natural History Study (NHS).

METHODS

A retrospective cohort study evaluated participants in the NHS, a cohort of HIV-positive active duty members and beneficiaries with HIV infection. Men with a diagnosis of ED after HIV diagnosis were included. Cohort controls without ED diagnosis were matched 2:1 by age at HIV diagnosis and duration of follow-up. Multivariate logistic regression models were used to identify factors associated with ED.

RESULTS

A total of 543 of 5682 male participants (9.6% prevalence) had a diagnosis of ED, of whom 488 were included in the analysis. The median (interquartile range, IQR) age at ED diagnosis was 43 (37.0-49.0) years and the time from HIV diagnosis to antiretroviral therapy (ART) start was longer for cases (5.0 years, IQR: 2.0-9.0) than for controls (3.0 years, 1.0-6.0; P < 0.01). Cases had higher proportions of multiple comorbid conditions, including depression (33.4% vs. 21.7%), tobacco use (19.7% vs. 9.0%) and sleep apnoea (14.8% vs. 4.2%) compared with controls (P < 0.01 for all). Logistic regression showed increased odds of ED for delayed ART initiation > 4 years [odds ratio (OR) = 2.05, 95% confidence interval (CI): 1.56-2.71], protease inhibitor use ≥ 1 year (OR = 1.81, 95% CI: 1.38-2.38) and sleep apnoea (OR = 2.60, 95% CI: 1.68-4.01).

CONCLUSIONS

Erectile dysfunction was common in men with HIV and associated factors included both HIV-related and traditional factors.

Women and barriers to harm reduction services: a literature review and initial findings from a qualitative study in Barcelona, Spain

Background

There are an estimated 3.2 million women who inject drugs worldwide, constituting 20% of all people who inject drugs. The limited data that are available suggest that women who inject drugs are at greater risk of HIV and viral hepatitis acquisition than men who inject drugs. This increased vulnerability is a product of a range of environmental, social and individual factors affecting women, which also affect their ability to engage in health promoting services such as harm reduction.

Methods

The researchers undertook a narrative literature review examining access to harm reduction services for women who use drugs in Europe and conducted semi-structured focus groups with women who use drugs and harm reduction and prison health workers in Barcelona, Spain.

Results

Women who use drugs face multiple barriers to accessing harm reduction services. These include stigma, both in society in general and from health and harm reduction workers in prisons and in the community; gender-based violence and a lack of services that are equipped to address the interaction between drug use and experiences of violence; criminalisation in the form of legal barriers to access, arrest and harassment from law enforcement, and incarceration; and a lack of services focused on the specific needs of women, notably sexual and reproductive health services and childcare. In Barcelona, participants reported experiencing all these barriers, and that their engagement with the Metzineres harm reduction centre had to some extent mitigated them. However, women continued to experience structural barriers to harm reduction service access.

Conclusions

Women and gender non-conforming people who use drugs face unique barriers to accessing harm reduction services. While services such as Metzineres can be life changing and life affirming for its members, it is incumbent on states to act to address the structural barriers to health faced by women who use drugs.

The eastern extent of seasonal iron limitation in the high latitude North Atlantic Ocean

The availability of iron (Fe) can seasonally limit phytoplankton growth in the High Latitude North Atlantic (HLNA), greatly reducing the efficiency of the biological carbon pump. However, the spatial extent of seasonal iron limitation is not yet known. We present autumn nutrient and dissolved Fe measurements, combined with microphytoplankton distribution, of waters overlying the Hebridean (Scottish) shelf break. A distinct biogeochemical divide was observed, with Fe deficient surface waters present beyond the shelf break, much further eastwards than previously recognised. Due to along and on-shelf circulation, the Hebridean shelf represents a much-localised source of Fe, which does not fertilise the wider HLNA. Shelf sediments are generally thought to supply large quantities of Fe to overlying waters. However, for this Fe to influence upper-ocean biogeochemical cycling, efficient off-shelf transport mechanisms are required. This work challenges the view that the oceanic surface waters in close proximity to continental margins are iron replete with respect to marine primary production demands.

Cost-effectiveness and resource implications of aggressive action on tuberculosis in China, India, and South Africa: a combined analysis of nine models

BACKGROUND

The post-2015 End TB Strategy sets global targets of reducing tuberculosis incidence by 50% and mortality by 75% by 2025. We aimed to assess resource requirements and cost-effectiveness of strategies to achieve these targets in China, India, and South Africa.

METHODS

We examined intervention scenarios developed in consultation with country stakeholders, which scaled up existing interventions to high but feasible coverage by 2025. Nine independent modelling groups collaborated to estimate policy outcomes, and we estimated the cost of each scenario by synthesising service use estimates, empirical cost data, and expert opinion on implementation strategies. We estimated health effects (ie, disability-adjusted life-years averted) and resource implications for 2016-35, including patient-incurred costs. To assess resource requirements and cost-effectiveness, we compared scenarios with a base case representing continued current practice.

FINDINGS

Incremental tuberculosis service costs differed by scenario and country, and in some cases they more than doubled existing funding needs. In general, expansion of tuberculosis services substantially reduced patient-incurred costs and, in India and China, produced net cost savings for most interventions under a societal perspective. In all three countries, expansion of access to care produced substantial health gains. Compared with current practice and conventional cost-effectiveness thresholds, most intervention approaches seemed highly cost-effective.

INTERPRETATION

Expansion of tuberculosis services seems cost-effective for high-burden countries and could generate substantial health and economic benefits for patients, although substantial new funding would be required. Further work to determine the optimal intervention mix for each country is necessary.

FUNDING

Bill & Melinda Gates Foundation.

Feasibility of achieving the 2025 WHO global tuberculosis targets in South Africa, China, and India: a combined analysis of 11 mathematical models

Background

The post-2015 End TB Strategy proposes targets of 50% reduction in tuberculosis incidence and 75% reduction in mortality from tuberculosis by 2025. We aimed to assess whether these targets are feasible in three high-burden countries with contrasting epidemiology and previous programmatic achievements.

Methods

11 independently developed mathematical models of tuberculosis transmission projected the epidemiological impact of currently available tuberculosis interventions for prevention, diagnosis, and treatment in China, India, and South Africa. Models were calibrated with data on tuberculosis incidence and mortality in 2012. Representatives from national tuberculosis programmes and the advocacy community provided distinct country-specific intervention scenarios, which included screening for symptoms, active case finding, and preventive therapy.

Findings

Aggressive scale-up of any single intervention scenario could not achieve the post-2015 End TB Strategy targets in any country. However, the models projected that, in the South Africa national tuberculosis programme scenario, a combination of continuous isoniazid preventive therapy for individuals on antiretroviral therapy, expanded facility-based screening for symptoms of tuberculosis at health centres, and improved tuberculosis care could achieve a 55% reduction in incidence (range 31–62%) and a 72% reduction in mortality (range 64–82%) compared with 2015 levels. For India, and particularly for China, full scale-up of all interventions in tuberculosis-programme performance fell short of the 2025 targets, despite preventing a cumulative 3·4 million cases. The advocacy scenarios illustrated the high impact of detecting and treating latent tuberculosis.

Interpretation

Major reductions in tuberculosis burden seem possible with current interventions. However, additional interventions, adapted to country-specific tuberculosis epidemiology and health systems, are needed to reach the post-2015 End TB Strategy targets at country level.

Funding

Bill and Melinda Gates Foundation

The need to accelerate access to new drugs for multidrug-resistant tuberculosis

Approximately half a million people are thought to develop multidrug-resistant tuberculosis annually. Barely 20% of these people currently receive recommended treatment and only about 10% are successfully treated. Poor access to treatment is probably driving the current epidemic, via ongoing transmission. Treatment scale-up is hampered by current treatment regimens, which are lengthy, expensive, poorly tolerated and difficult to administer in the settings where most patients reside. Although new drugs provide an opportunity to improve treatment regimens, current and planned clinical trials hold little promise for developing regimens that will facilitate prompt treatment scale-up. In this article we argue that clinical trials, while necessary, should be complemented by timely, large-scale, operational research that will provide programmatic data on the use of new drugs and regimens while simultaneously improving access to life-saving treatment. Perceived risks - such as the rapid development of resistance to new drugs - need to be balanced against the high levels of mortality and transmission that will otherwise persist. Doubling access to treatment and increasing treatment success could save approximately a million lives over the next decade.

Multi-channel Andreev reflection in Co-W nanocontacts fabricated using focused electron/ion beam induced deposition

We report multi-channel electron transport in nano-contacts fabricated using focused electron beam induced deposited (FEBID) cobalt and focused ion beam induced deposited (FIBID) tungsten. Anomalous Andreev reflection (AR) effect is observed to which the conventional Blonder-Tinkham-Klapwijk (BTK) fit cannot be applied. In specific, we have observed multiple number of shoulders near the AR peak, whose origin is unknown in literature. We explain this effect based on a simple model that takes into account the material properties of the FIBID grown W superconductor, as well as the specific interface properties that are an outcome of using FEBID/FIBID as a fabrication technique. We show that numerical calculations using the BTK approximation based on the consideration of multiple channels generate similar shoulders as we observed in the AR experiments. Electrical measurements and x-ray photoemission spectroscopy carried out on FIBID W deposits puts additional evidence towards multi-channel current transport occuring at the interface of the nanocontacts.

Alignment of new tuberculosis drug regimens and drug susceptibility testing: a framework for action

New tuberculosis drug regimens are creating new priorities for drug susceptibility testing (DST) and surveillance. To minimise turnaround time, rapid DST will need to be prioritised, but developers of these assays will need better data about the molecular mechanisms of resistance. Efforts are underway to link mutations with drug resistance and to develop strain collections to enable assessment of new diagnostic assays. In resource-limited settings, DST might not be appropriate for all patients with tuberculosis. Surveillance data and modelling will help country stakeholders to design appropriate DST algorithms and to decide whether to change drug regimens. Finally, development of practical DST assays is needed so that, in countries where surveillance and modelling show that DST is advisable, these assays can be used to guide clinical decisions for individual patients. If combined judiciously during both development and implementation, new tuberculosis regimens and new DST assays have enormous potential to improve patient outcomes and reduce the burden of disease.

Community-based multi-disease prevention campaigns for controlling human immunodeficiency virus-associated tuberculosis

Human immunodeficiency virus (HIV) infection increases the risk of tuberculosis (TB) 21-34 fold, and has fuelled the resurgence of TB in sub-Saharan Africa. The World Health Organization (WHO) recommends the Three I's for HIV/TB (infection control, intensified case finding [ICF] and isoniazid preventive therapy) and earlier initiation of antiretroviral therapy for preventing TB in persons with HIV. Current service delivery frameworks do not identify people early enough to maximally harness the preventive benefits of these interventions. Community-based campaigns were essential components of global efforts to control major public health threats such as polio, measles, guinea worm disease and smallpox. They were also successful in helping to control TB in resource-rich settings. There have been recent community-based efforts to identify persons who have TB and/or HIV. Multi-disease community-based frameworks have been rare. Based on findings from a WHO meta-analysis and a Cochrane review, integrating ICF into the recent multi-disease prevention campaign in Kenya may have had implications in controlling TB. Community-based multi-disease prevention campaigns represent a potentially powerful strategy to deliver prevention interventions, identify people with HIV and/or TB, and link those eligible to care and treatment.

Voxel-based morphometry shows no decreases in cerebellar gray matter volume in essential tremor

OBJECTIVE

To investigate cerebellar gray matter volume in patients with essential tremor (ET).

METHODS

We used voxel-based morphometry (VBM) based on high-resolution T1-weighted MRI to compare gray and white matter density between 27 patients with ET and 27 age- and sex-matched healthy control subjects. Fourteen patients had only postural tremor, whereas 13 patients showed additional intention tremor.

RESULTS

VBM failed to demonstrate regional decreases in gray and white matter volume in patients with ET. There was, however, an expansion in gray matter depending on the type of tremor. Compared with age-matched control groups, patients with intention tremor showed a relative expansion of gray matter bilaterally in the region of the temporoparietal junction and the right middle occipital cortex.

CONCLUSIONS

The lack of a consistent decrease in gray and white matter density argues against a progressive neurodegenerative process in essential tremor that leads to a substantial decrease in cerebellar gray matter volume. Patients with predominant intention tremor show a relative expansion of gray matter areas involved in higher order visuospatial processing, which might represent a long-term result of adaptive reorganization compensating the higher demands on the visuospatial control of skilled movements in case of trembling.

High-dose rituximab and anti-MAG-associated polyneuropathy

Rituximab has been administered successfully in patients with polyneuropathy associated with antibodies to myelin-associated glycoprotein (anti-MAG). The authors present a follow-up study with high-dose rituximab. Increase of rituximab from 375 mg/m2 to a dose of 750 mg/m2 was well tolerated and led to clinical improvement in four of eight patients, along with improvement of nerve conduction velocities and a reduction of anti-MAG antibody titers.

Abnormal response to inotropic stimulation in young asymptomatic type I diabetic patients demonstrated by serial gated myocardial perfusion SPECT imaging

PURPOSE

In subjects without underlying cardiac disease dobutamine is known to enhance systolic LV function and LV relaxation. As end-systolic (ES) and end-diastolic (ED) volumes (V) can be derived from gated SPECT we intent to study these volumes and their response to dobutamine in order to have a better understanding of the mechanism by which stroke volume (SV) increases during dobutamine infusion. We intent to do this in normal controls and in young diabetic subjects.

METHODS

After injection of sestamibi, serial gated SPECT were obtained at baseline, and during low doses of dobutamine infusion in 12 asymptomatic type I diabetic patients, and in 12 age matched controls. LV EDV, ESV, SV and EF were calculated with the QGS program.

RESULTS

Gated SPECT showed comparable LV EF and SV in both groups at rest. There was a significant increase in LVEF and SV during dobutamine infusion but in the diabetic patients the increase in SV was due to a decrease in ESV from 25+/-5 to 20+/-6 ml/m2 (p=0.002) and no change in EDV. In normal controls, the increase in EF was due to an increase in EDV from 69+/-10 to 73+/-12 ml/m2 (p=0.002) with no significant change in ESV.

CONCLUSION

These data confirm the presence of subclinical abnormalities of diastolic function in asymptomatic type I diabetic patients and show differences in adaptation to inotropic stimulation in order to preserve the increase in stroke volume and LV ejection fraction.

The European Multiple System Atrophy-Study Group (EMSA-SG)

Introduction. The European Multiple System Atrophy-Study Group (EMSA-SG) is an academic network comprising 23 centers across Europe and Israel that has constituted itself already in January 1999. This international forum of established experts under the guidance of the University Hospital of Innsbruck as coordinating center is supported by the 5th framework program of the European Union since March 2001 (QLK6-CT-2000-00661). Objectives. Primary goals of the network include (1) a central Registry for European multiple system atrophy (MSA) patients, (2) a decentralized DNA Bank, (3) the development and validation of the novel Unified MSA Rating Scale (UMSARS), (4) the conduction of a Natural History Study (NHS), and (5) the planning or implementation of interventional therapeutic trials. Methods. The EMSA-SG Registry is a computerized data bank localized at the coordinating centre in Innsbruck collecting diagnostic and therapeutic data of MSA patients. Blood samples of patients and controls are recruited into the DNA Bank. The UMSARS is a novel specific rating instrument that has been developed and validated by the EMSA-SG. The NHS comprises assessments of basic anthropometric data as well as a range of scales including the UMSARS, Unified Parkinson's Disease Rating Scale (UPDRS), measures of global disability, Red Flag list, MMSE (Mini Mental State Examination), quality of live measures, i.e. EuroQoL 5D (EQ-5D) and Medical Outcome Study Short Form (SF-36) as well as the Beck Depression Inventory (BDI). In a subgroup of patients dysautonomic features are recorded in detail using the Queen Square Cardiovascular Autonomic Function Test Battery, the Composite Autonomic Symptom Scale (COMPASS) and measurements of residual urinary volume. Most of these measures are repeated at 6-monthly follow up visits for a total study period of 24 months. Surrogate markers of the disease progression are identified by the EMSA-SG using magnetic resonance and diffusion weighted imaging (MRI and DWI, respectively). Results. 412 patients have been recruited into the Registry so far. Probable MSA-P was the most common diagnosis (49% of cases). 507 patients donated DNA for research. 131 patients have been recruited into the NHS. There was a rapid deterioration of the motor disorder (in particular akinesia) by 26.1% of the UMSARS II, and - to a lesser degree - of activities of daily living by 16.8% of the UMSARS I in relation to the respective baseline scores. Motor progression was associated with low motor or global disability as well as low akinesia or cerebellar subscores at baseline. Mental function did not deteriorate during this short follow up period. Conclusion. For the first time, prospective data concerning disease progression are available. Such data about the natural history and prognosis of MSA as well as surrogate markers of disease process allow planning and implementation of multi-centre phase II/III neuroprotective intervention trials within the next years more effectively. Indeed, a trial on growth hormone in MSA has just been completed, and another on minocycline will be completed by the end of this year.

Self-report measure of low back-related biomechanical exposures: clinical validation

Low back pain and symptoms are major contributors to ambulatory visits, economic burden, and reduced readiness among military personnel and employers in the civilian workplace as well. While a link between low back pain and biomechanical exposures has been established, efficient surveillance methods of such exposures are still needed. Furthermore, the utility of self-report measures for biomechanical exposures has not been examined extensively. The present cross-sectional study analyzed questionnaire data from US Army soldiers (n = 279) working in previously identified occupational specialties that were associated with high risk for low back pain and/or low back pain disability. Demographic characteristics, physical workload, health behaviors, and psychosocial factors were assessed in addition to self-reported workplace biomechanical exposures using the Job Related Physical Demands (JRPDs). Outcomes included self-reported low back pain severity, low back symptoms, functional limitations, and general physical health. The results indicated that the self-report measure of biomechanical exposure had a high degree of internal consistency (Cronbach alpha, 0.95). The JRPD index correlated with low back symptoms, pain intensity, function, and perceived work load using the Borg scale. Regression analyses indicated statistically significant associations between the JRPD and back pain specific pain severity and physical function, but not for general physical health (SF-12) after controlling for age, gender, educational level, job type, and reported exercise and work stress. Specifically, higher JRPD scores (representing greater biomechanical exposure) were associated with higher levels of pain intensity and functional limitations. Higher JRPD scores were found to place an individual at a greater likelihood for being a case with low back pain within the past 12 months (OR = 1.01 per point increase in scale-95%; range 38-152; CI = 1.00-1.02, p < or = 0.05). While future longitudinal studies of the JRPD determining the predictive validity of the measure are needed, the present study provides evidence of the utility of the JRPD for assessing biomechanical exposures associated with low back pain within high-risk jobs. The findings suggest that the JRPD may assist with surveillance efforts and be useful as a process and/or outcome measure in research related to occupational rehabilitation.

A microsatellite genetic linkage map for Xiphophorus

Interspecies hybrids between distinct species of the genus Xiphophorus are often used in varied research investigations to identify genomic regions associated with the inheritance of complex traits. There are 24 described Xiphophorus species and a greater number of pedigreed strains; thus, the number of potential interspecies hybrid cross combinations is quite large. Previously, select Xiphophorus experimental crosses have been shown to exhibit differing characteristics between parental species and among the hybrid fishes derived from crossing them, such as widely differing susceptibilities to chemical or physical agents. For instance, genomic regions harboring tumor suppressor and oncogenes have been identified via linkage association of these loci with a small set of established genetic markers. The power of this experimental strategy is related to the number of genetic markers available in the Xiphophorus interspecies cross of interest. Thus, we have undertaken the task of expanding the suite of easily scored markers by characterization of Xiphophorus microsatellite sequences. Using a cross between Xiphophorus maculatus and X. andersi, we report a linkage map predominantly composed of microsatellite markers. All 24 acrocentric chromosome sets of Xiphophorus are represented in the assembled linkage map with an average intergenomic distance of 7.5 cM. Since both male and female F1 hybrids were used to produce backcross progeny, these recombination rates were compared between "male" and "female" maps. Although several genomic regions exhibit differences in map length, male- and female-derived maps are similar. Thus Xiphophorus, in contrast to zebrafish, Danio rerio, and several other vertebrate species, does not show sex-specific differences in recombination. The microsatellite markers we report can be easily adapted to any Xiphophorus interspecies and some intraspecies crosses, and thus provide a means to directly compare results derived from independent experiments.

Evaluating the Cost-Effectiveness of Orthodontic Provision

The assessment of orthodontic provision is important to determine if treatment was necessary and undertaken appropriately. The ICON objectively quantifies orthodontic treatment need, complexity and outcome and is a valuable occlusal index in the assessment effectiveness of orthodontic care. It is possible to develop cost-effectiveness models by analysing the costs and effectiveness of orthodontic treatment. Several methods are illustrated to compare the orthodontic provision of specialist orthodontists.

Pioneers of movement disorders: Georges Gilles de la Tourette

Georges Albert Edouard Brutus Gilles de la Tourette (1857-1904), a French neurologist and pupil of Jean Martin Charcot at the Salpêtrière hospital in Paris, has gained common recognition through his description of the 'Maladie des Tics'. This complex neuropsychiatric disorder, later known as the 'Tourette's syndrome', nowadays is accepted as a specific entity of movement disorders. Gilles had started working under Charcot (1825-1893), the first physician to occupy a designated chair of neurology of neuropsychiatric history, in 1884. Then the Salpêtrière hospital was a centre of intensive research with an emphasis on hysteria and hypnosis. Tourette took an interest in hysteria, but also dedicated himself to various other neuropsychiatric disorders and to neuropathology. He published scientific works on epilepsia, neurasthenia and syphilitic myelitis. Although he devoted much time to his neuropsychiatric research and the publication of articles in medical journals, his career did not make significant progress, despite Charcot's unrestricted support. One reason was, that he disregarded questions, answers and problems, which were outside his interest fields. Hence, he was accused for having acquired an extremely filtered and one-sided knowledge. Also, his alienated and critical behaviour, which had not helped him to find many friends over the years, prevented him from professional promotion. In 1893 an assassination attempt on Gilles de la Tourette raised considerable public interest: Gilles was shot in his appartement in the Rue de l'Université 39 by a young woman, who had been his patient in the Salpêtrière and who claimed that she had been hypnotized without her agreement and thereby had lost her mental health. However, the patient was diagnosed with a disease nowadays called paranoid schizophrenia and therefore hypnosis was not attributed to any part of the disease. Due to episodes of melancholia and phases of delusions of grandeur and megalomania Gilles de la Tourette was forced to leave his hospital appointment in 1901. These symptoms and the corresponding neurological signs were attributed to the paretic neurosyphilis. He was institutionalized to the psychiatric hospital Cery near Lausanne, Switzerland. In the course of the following three years he became increasingly psychotic and demented, suffered from epileptic seizures and finally died in hospital on 22nd May 1904.

Contrast harmonic imaging improves the evaluation of left ventricular function in ventilated patients: comparison with transesophageal echocardiography

AIMS

The study examined the value of contrast echocardiography (CE) in the assessment of left ventricular (LV) wall motion in ventilated patients in comparison with transesophageal (TOE) and standard fundamental transthoracic imaging (SE).

METHODS

Transthoracic echocardiograms were done in 40 ventilated patients. Wall motion was evaluated using the recommendations of the American Society of Echocardiography on SE, CE and TOE. A visualization score was assigned on a scale of 2-0 for each of 16 segments. The segment was assigned a value of 2 if the segment was seen in both systole and diastole, 1 if seen only in systole or diastole, and 0 if not seen at all. A confidence score was also given for each segment with each technique (unable to evaluate; not sure; sure). The ejection fraction (EF) was estimated visually for each technique, and a confidence score was also applied to the EF.

RESULTS

Visualization score 0 was present in 6.2 segments/patient on SE, 1.2 on CE (P<0.0001) and 1.1 on TOE (P<0.0001). An average of 6.5 segments were read with surety on SE, 11.5 on CE (P<0.0001) and 12.3 on TOE ( P<0.0001 ). There was no significant difference for CE vs TOE. EF was uninterpretable in 32% on SE, 0% on CE (P<0.001 and 0% on TOE (P<0.001). The EF was read with surety in 53% of patients on SE, 88% on CE (P < 0.0001) and 93% with TOE (P<0.0001) with no difference for CE vs TOE. Thus, wall motion was seen with more confidence on CE and TOE.

CONCLUSIONS

In the ventilated patients with suboptimal transthoracic echocardiograms for the evaluation of the LV function, CE provides image quality of regional and global LV function similar to that achieved with TOE echocardiography.